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I. Avogadro, M.B. B.CH., M.B.B.Ch., Ph.D.

Associate Professor, University of the Virgin Islands

The risk of infection by male-to-male receptive anal intercourse has been estimated to be between 1 in 10 and 1 in 1600, by maleto-female vaginal intercourse has been estimated to be 1 in 200 to 1 in 2000, and by female-to-male vaginal intercourse has been estimated to be between 1 in 700 and 1 in 3000 [25]. In addition to specific perinatal prophylaxis, the availability of safe infant formula feeding to replace breastfeeding and of selective utilization of cesarean delivery has made perinatal transmission a rare event in developed countries [27, 28]. Computerized literature searches of PubMed (for articles from January 2000 to December 2008) were performed. Data published after December 2008 were also considered in the final preparation of the manuscript. The process included a systematic weighting of the quality of the evidence and the grade of recommendation [30] (table 2). Consensus Development on the Basis of Evidence the Panel met on several occasions via teleconference and worked via e-mail communications to complete the work of these guidelines. The purpose of the teleconferences was to discuss the questions to be addressed, make writing assignments, and discuss recommendations. All members of the panel participated in the preparation and review of the draft guidelines. Attributes of good guidelines include validity, reliability, reproducibility, clinical applicability, clinical flexibility, clarity, multidisciplinary process, review of evidence, and documentation" [29, p. Information was requested regarding employment, consultancies, stock ownership, honoraria, research funding, expert testimony, and membership on company advisory committees. A positive or reactive screening test result is confirmed by Western blot or indirect immunofluorescence assay. Several of these tests can be performed on whole blood specimens obtained by fingerstick or venipuncture, all of them can be performed on plasma specimens, and all but the Oraquick test can be performed on serum specimens. Clinicians should review the package inserts to understand the limitations of the test being used. Some authorities recommend that a positive oral rapid test result be routinely confirmed with a whole blood rapid test because of the potential for a higher frequency of false-positive results with the oral rapid test [31]. Specimens reactive on screening tests are interpreted to be "preliminary positive" and must be confirmed by Western blot or indirect immunofluorescence assay, even if a subsequent conventional screening test is not reactive [32]. In limited circumstances, action may be indicated on the basis of the preliminary positive results of screening tests. Providers should be aware of state and local laws or regulations regarding informed consent. This checklist can be administered by the patient or clinician and should take 4 min. A positive response to any of the screening questions should cue the clinician to have a more in-depth discussion to ensure that specific risks are clearly understood. General messages regarding risk reduction should be provided at all health care encounters, regardless of risk behaviors reported by the patient or perceived risk on the part of the health care provider. In nearly all situations, the provider should offer brief counseling; in general, persons exhibiting risk behavior should also be referred to programs capable of offering more extensive intervention programs (A-I). It is critical to obtain a thorough medication history for patients who have already received antiretroviral therapy. Every effort should be made to obtain medical records from previous health care providers. Providers should inquire about chronic medical conditions, such as peripheral neuropathy, gastrointestinal disease, chronic viral hepatitis, hyperlipidemia, diabetes mellitus, or renal insufficiency, that might affect the choice of therapy or response to therapy. It is important that the history also include questions about where the patient has traveled and lived. For example, patients reporting travel in areas of endemicity for histoplasmosis (Ohio and Mississippi River valleys) or coccidioidomycosis (southwestern deserts) may be at risk for reactivation disease, even after moving to areas in which these infections are not endemic. The status of adult immunizations, including tetanus toxoid, pneumococcal vaccine, and hepatitis A and B vaccines, should be elicited. A full birth history and review of maternal history and risk factors should be available for all children. Patients should be asked about any medications they take, including prescription and overthe-counter drugs, methadone, and dietary or herbal supplements, some of which have been shown to interact with antiretroviral drugs.

Induction of unresponsiveness against IgA in IgA-deficient patients on subcutaneous immunoglobulin infusion therapy. Safety and efficacy of self-administered subcutaneous immunoglobulin in patients with primary immunodeficiency diseases. Quality of life and health-care resource utilization among children with primary immunodeficiency receiving home treatment with subcutaneous human immunoglobulin. Immunoglobulin treatment for primary antibody deficiencies: advantages of the subcutaneous route. Pharmacokinetics of subcutaneous immunoglobulin and their use in dosing of replacement therapy in patients with primary immunodeficiencies. Safety and efficacy of Privigen, a novel 10% liquid immunoglobulin preparation for intravenous use, in patients with primary immunodeficiencies. Home therapy with subcutaneous immunoglobulin infusions in children with congenital immunodeficiencies. Self-infusion programmes for immunoglobulin replacement at home: feasibility, safety and efficacy. Children and adults with primary antibody deficiencies gain quality of life by subcutaneous IgG self-infusions at home. Efficacy and safety of Hizentra((R)) in patients with primary immunodeficiency after a dose-equivalent switch from intravenous or subcutaneous replacement therapy. Higher doses of subcutaneous IgG reduce resource utilization in patients with primary immunodeficiency. Subcutaneous immunoglobulin (16 or 20%) therapy in obese patients with primary immunodeficiency: a retrospective analysis of administration by infusion pump or subcutaneous rapid push. Therapeutic immunoglobulin should be dosed by clinical outcome rather than by body weight in obese patients. Serum trough IgG level and annual intravenous immunoglobulin dose are not related to body size in patients on regular replacement therapy. Rapid subcutaneous immunoglobulin administration every second week results in high and stable serum immunoglobulin G levels in patients with primary antibody deficiencies. Human immunoglobulin 10% with recombinant human hyaluronidase: replacement therapy in patients with primary immunodeficiency disorders. Subcutaneous immunoglobulin therapy by rapid push is preferred to infusion by pump: a retrospective analysis. Pharmacokinetics of immunoglobulin administered via intravenous or subcutaneous routes. Improved quality of life, immunoglobulin G levels, and infection rates in patients with primary immunodeficiency diseases during self-treatment with subcutaneous immunoglobulin G. Immunoglobulin dosage and switch from intravenous to subcutaneous immunoglobulin replacement therapy in patients with primary hypogammaglobulinemia: decreasing dosage does not alter serum IgG levels. Economic assessment of different modalities of immunoglobulin replacement therapy. Idiopathic thrombocytopenic purpura in a boy with ataxia telangiectasia on immunoglobulin replacement therapy. Home-based subcutaneous immunoglobulin G replacement therapy under real-life conditions in children and adults with antibody deficiency. Pharmacoeconomic advantages of subcutaneous versus intravenous immunoglobulin treatment in a Canadian pediatric center. Economic evaluation of immunoglobulin replacement in patients with primary antibody deficiencies. Progress in gammaglobulin therapy for immunodeficiency: from subcutaneous to intravenous infusions and back again. Subcutaneous immunoglobulin therapy given by subcutaneous rapid push vs infusion pump: a retrospective analysis. Subcutaneous self-infusions of immunoglobulins as a potential therapeutic regimen in immune-mediated neuropathies.

However, if the worsening cough is associated with high fever, difficulty breathing, worsening cough etc, then pneumonia / asthma should also be considered. It is important to remember that facial pain, headache, and fever, are not common symptoms of sinusitis in children. Assess air-entry, differentiate transmitted upper airway sounds, crackles, rhonchi and wheezing. In making a diagnosis of sinusitis, should imaging studies be ordered on every patient Sinusitis is essentially a clinical diagnosis and should be treated based on history. The use of imaging studies in an otherwise healthy child with suspected sinusitis is controversial. They should be ordered in patients with poor response to therapy or with suspected complications. Sinus radiographs have been found to be unreliable unless read by an experienced pediatric radiologist (especially in children under 1 year), and should only be obtained in patients who have failed antibiotic therapy. Nasal, oropharyngeal, and nasopharyngeal cultures correlate poorly with cultures of sinus aspirates and is not indicated in the diagnostic workup of acute or chronic sinusitis. However, as this is an invasive procedure, it is usually performed in patients with orbital or intracranial complications. For those with sinusitis of moderate severity, those treated with antibiotics previously and those that attend day care and have been treated with multiple antibiotics, high dose Amoxicillinclavulanate, (80 -90 mg/kg/day), Cefdinir, Cefuroximes or Cefpodoxime can be used. The duration of therapy also is somewhat controversial, but typically ranges from 14-21days. An eleven-year-old presents with frequent episodes of a coughing illness often triggered by colds. Review of Important Concepts: Historical Points In an eleven year old, frequent episodes of "colds with episodes of coughing" could be due to asthma, allergic rhinitis or both. In addition, some of these episodes could be from sinusitis secondary to allergic rhinitis. In children, it is important to identify the etiology of the cough, especially when it has lasted over 4 weeks (chronic cough). Family history of asthma, wheezing, shortness of breath with or without exertion, history of atopy and night time coughing, would suggest a diagnosis of asthma. It is important to remember that a history of frequent episodes of bronchitis, that has been treated on multiple occasions with antibiotics, may mean that the child has asthma. Purulent nasal discharge with the coughing spells, facial tenderness, headache, peri-orbital swelling would suggest sinusitis most likely secondary to allergic rhinitis. It is also important that the student takes a good environmental history to identify any triggers such as smoke exposure, dust mites and presence of pets. Wheezing, decreased air entry, skin findings of atopy and prolonged expiratory phase would indicate underlying asthma, though in some patients with cough-variant asthma, wheezing may not be evident at each visit. In patients with allergic rhinitis, physical exam will reveal pale, blue, swollen nasal mucosa, watery discharge from eye/ nose and allergic shiners. If recurrent sinusitis is the cause of the recurrent cough, then it is important to look for a history of underlying cause such as allergic rhinitis. In a patient with frequent episodes of coughing associated with colds, what would be the next step in management With a clear history and physical exam to support a diagnosis of asthma, a trial of beta agonists (with or without inhaled corticosteroids) can be prescribed for a limited time. Improvement would suggest a diagnosis of asthma, but it is important to establish a definitive diagnosis based on spirometry. It is also reasonable to obtain a chest x-ray in a child with a recurrent cough (may show evidence of hyperinflation and peribrochial thickening in the case of asthma). However, most physicians would do empiric therapy first in an outpatient setting in the face of a clear history and physical exam findings. Empiric therapy should be time limited, the patient should be re-evaluated in 2-4 weeks for improvement and eventually a definitive diagnosis should be established.